Spotlight: National Minority Health Month

April 2016

April is National Minority Health Month. Minority populations include Hispanic/Latino, African American, American Indian/Alaska Native, Asian American, and Native Hawaiian/Other Pacific Islander. According to 2012 U.S. Census Bureau population estimates, there are nearly 53 million Hispanics living in the United States, representing the largest minority population and 17% of the total population, while African Americans represent the second largest minority population at 43 million.1 According to the 2012 Minority Veterans Report, minority Veterans made up about 21% of the total Veteran population in 2012: the two largest groups were African American (11%) and Hispanic (6%). Moreover, the Veteran population is getting more and more diverse with the Post-9/11 and Pre-9/11 cohorts having the highest number of minorities. This Report predicts that while the overall Veteran population will decrease from 22.3 million in 2012 to 14.5 million in 2040, the percent of minority Veterans will increase over this same time period from 21% to 34%.

HSR&D Research on Minority Health

Understanding how to reduce disparities in healthcare quality and outcomes is critical to achieving VHA's mission of maximizing the health of the Veteran population. HSR&D funds two Centers of Innovation that specifically focus on issues related to health equity, including the Charleston Health Equity and Rural Outreach Innovation Center and the Center for Health Equity Research & Promotion. HSR&D also collaborates with the VHA Office of Health Equity (intranet only: http://vaww.pdush.med.va.gov/programs/ohe/oheDefault.aspx) on the Office of Health Equity-QUERI Partnered Evaluation Initiative. Following are descriptions of just a few select studies that HSR&D investigators are conducting on issues important to providing optimal healthcare for minority Veterans.

Measuring Cross-Cultural Competence in VA Primary Care

Over the last decade, the desire to reduce provider contributions to racial disparities has led to widespread calls to train providers in "cultural competence" (CC). The primary goal of CC training is to equip clinicians with the knowledge, attitudes, and skills to address potential sources of disparities in healthcare quality, by improving their communication and relationships with patients from diverse backgrounds. The primary objective of this HSR&D study was to determine which dimensions of healthcare provider CC are associated with better relationships and greater equity of care across racial/ethnic groups. Investigators developed a self-administered instrument for primary care providers (PCPs) consisting of six scales that represent different CC dimensions: Perceived Cultural Aptitude, Perceived Cross-Cultural Efficacy, Awareness of Racial Disparities, Valuing Diverse Perspectives, Support for Accommodating Patient Diversity, and Patient-Centered Orientation. In this study, 97 PCPs at four geographically diverse VA medical centers completed the CC instrument, and 1,016 Veterans were surveyed to measure their experience with PCPs' communication and interpersonal style, and their trust in the PCP.

PCPs scoring above the median on the VDP scale received significantly higher ratings from African American Veterans on communication quality and interpersonal skill. Higher VDP was not significantly associated with white patients' ratings of providers.

Ratings of higher CC providers were not significantly different between white and African American Veterans on any of the outcome measures.

Motivating Providers to Reduce Racial Disparities

There is broad consensus that increasing the ability of clinicians and other healthcare employees to address disparities is a critical part of eliminating disparities. What is missing, however, are empirically-based communication strategies motivating providers to reduce disparities. This ongoing HSR&D study uses theories of message framing and narrative communication to explore the role of pre-existing beliefs about the causes of healthcare inequality on providers' responses to persuasive narratives that differ in their framing of the issue. Investigators conducted interviews with 53 providers from three VA facilities to identify the types of messages that would be most persuasive for providers with different beliefs about the causes of healthcare inequality. They also are currently fielding a survey to test the hypothesis that narratives that are congruent with providers' beliefs about the cause of racial differences in healthcare quality will be most effective at increasing providers' readiness to engage in disparities-reduction activities. This survey also will help identify the narrative type that leads to the highest level of participation in disparities-reduction training across all providers. Thus far, findings from the qualitative study show:

Providers varied in their beliefs about the existence and causes of racial healthcare inequality. Some providers endorsed the existence of disparities and that provider bias played a role. Others endorsed the existence of disparities in the U.S., but believed that disparities were rare or non-existent in VA â€“ and that VA providers are unlikely to perpetuate bias.

Several misconceptions about disparities appeared to contribute to this perception.

Some providers believed that disparities are primarily due to lack of health insurance and limited access to care, and that disparities in VA were rare because of the lack of financial barriers.

Some providers did not recognize that racial bias could be unconscious rather than overt and believed disparities were rare because they did not witness explicit racial discrimination.

Some providers acknowledged patient mistrust as a contributor to disparities but attributed it to historical instances of racism (e.g., Tuskegee), dismissing the possibility of ongoing discrimination in health care.

Providers who acknowledged disparities often highlighted non-race-based reasons for differences in care, including patient factors such as non-adherence to medication, mental illness, and cultural beliefs.

Providers' preexisting beliefs about the causes of healthcare inequality were related to how they responded to different types of narratives about the issue.

Providers who did not believe that factors external to patients contribute to healthcare inequality resonated with "patient breakthrough" narratives, in which problems faced by minority patients were successfully resolved by a provider, but resisted "race conscious" narratives in which those problems were explicitly linked to issues of race and racism and remained unresolved.

Providers who believed that factors external to patients contribute to healthcare inequality resonated with both "race conscious" and "personal breakthrough" narratives.

Implications: This study provides a foundation for and raises important questions about developing effective communication strategies about disparities. It is expected to provide knowledge about how to increase provider readiness to engage in actions that will reduce healthcare disparities, and to project deliverables aimed at motivating providers to participate in programs designed to raise awareness and build skills to reduce healthcare disparities.

Using Stories to Address Disparities in Hypertension

Control rates for hypertension (HTN) among minority Veterans, in particular African American Veterans, are significantly lower compared to white Veterans. Poor HTN control leads to higher rates of organ damage, stroke, and cardiovascular complications. Few strategies to improve HTN control have focused on culturally-sensitive interventions to improve control among African American Veterans. Moreover, providing information in a narrative form (i.e. stories) has been found to be an effective mode of delivering health information. This ongoing HSR&D study builds on the investigators' prior work to evaluate the effectiveness of a "Stories" intervention among African American patients at three VA medical centers with a high prevalence of African American Veterans. Investigators are recruiting 30 African American Veterans and will videotape them telling their actual stories about managing their blood pressure. With these stories, they will develop an interactive multimedia intervention targeted to African American patients, "Stories to Communicate about Managing Hypertension," and deliver it using an easy-to-use DVD resource. Investigators then plan to conduct a randomized controlled trial to evaluate HTN stories delivered to African American outpatients with uncontrolled blood pressure - and compare the DVD stories intervention to an informational control (blood pressure education DVD, non-narrative).

Implications: The "Stories" intervention has the potential to greatly influence blood pressure management behavior for African American Veterans. This study will help to assess the impact of the intervention on both patient behavior and outcomes, with products that include a reusable manual and protocol for efficiently developing stories-based intervention in multiple conditions, a training curriculum for research assistants, and a "Stories" DVD for use in VA outpatient settings.

Walking Trial to Reduce Pain among Black Veterans

Chronic musculoskeletal (MSK) pain is one of the most common conditions among Veterans, affecting approximately 60% of those seen in VA primary care. Although perceived effectiveness of chronic pain treatment is low among all VA patients, black patients are less likely than whites to perceive their treatment as effective, and are more likely to experience functional limitations due to pain. There is growing consensus that chronic pain is best addressed by a biopsychosocial approach that acknowledges the role of psychological and environmental contributors to pain, some of which differ by race and, hence, contribute to disparities. For example, blacks experience greater pain-related fear and lower self-efficacy in coping with pain (psychological contributors), and neighborhoods that make physical activity difficult (environmental contributors). However, there is a lack of effective interventions to improve pain treatment among minority patients, particularly those that target psychological and environmental contributors. The primary objective of this newly funded HSR&D study is to test the effectiveness of a multi-component intervention that specifically targets known barriers to effective pain care among black Veterans with chronic MSK pain. Investigators have developed a telephone-delivered intervention that emphasizes walking and incorporates action planning, motivational interviewing, and cognitive behavioral therapy techniques, as well as the use of pedometers. They will test the effectiveness of this intervention in a randomized trial that compares it to usual care among 250 black and 250 non-black Veterans with chronic MSK pain, in addition to emotional functioning, and ratings of overall improvement.

Implications: The research is expected to result in a non-pharmacological intervention, delivered by telephone and designed to reduce pain and improve functioning among black patients with MSK pain by promoting walking.

Mental Health Disparities and Communication among African American Veterans

Patient-provider communication has been identified as one of the key mediators for racial health disparities in physical and mental health. Yet the views and experiences of ethnic minority Veterans regarding health communication, especially in mental health, remain under-studied. The lack of research in this area perpetuates a critical gap in our understanding of how ethnic minority groups understand and experience treatment decision-making. It also limits VA's continuing efforts to provide quality mental health services to ethnic minority groups, a fast growing Veteran population. This ongoing HSR&D study investigates the processes, facilitators, and barriers to mental health treatment decisions for African American Veterans. Investigators will conduct interviews with 36 African American Veterans receiving VA outpatient psychiatric care and 9 VA mental healthcare providers to identify barriers and facilitators to patient engagement and treatment decisions in mental healthcare. Veterans also will complete self-report measures that assess patient-provider working alliances, attitudes towards medication, and patient activation. Finally, investigators will compare how decisions are made among white and African American Veterans with mental illness, and use the findings to develop models for an intervention aimed at improving shared decision-making among African American Veterans.

Implications: This study will contribute to VA's efforts to implement its comprehensive Mental Health Strategic Plan, and also will lead to the design of an intervention for reducing health disparities and supporting mental health recovery among Veterans of ethnic minority backgrounds.

An Intervention to Reduce Osteoarthritis Pain Disparities

Arthritis is a prevalent and disabling source of chronic pain for which African Americans bear a disproportionate burden. This ongoing HSR&D study is testing a patient-centered, non-invasive intervention to improve pain outcomes and reduce disparities among African American and white Veterans with knee arthritis. The intervention was developed to help Veterans develop a positive mindset, the health benefits of which are well-documented. A randomized design is being used to assess the effects of a six-week positive activities program on pain and functioning at one-, three-, and six-months post-intervention. To date, 100 African American and 95 white primary care patients with symptomatic knee arthritis have been enrolled at two participating VA medical centers. The program consists of at-home activities that have been shown to increase positivity. Participants receive weekly telephone calls from trained interventionists to assess program completion and clarify instructions. Outcomes, including self-reported pain and physical functioning, will be assessed, in addition to potential mediating variables such as depressive symptoms, positive/negative affect, satisfaction with life, arthritis self-efficacy, pain coping, pain catastrophizing, perceived discrimination, global stress, and social support. Recruitment is ongoing, with a target enrollment of 360 Veterans.

Implications: In the future, this program could be used by Veterans with other chronic pain conditions and adapted for widespread implementation using electronic modalities.

Cardiovascular disease (CVD) is the leading cause of death in the U.S.; more than 80% of Veterans have more than two risk factors for CVD. Additionally, certain groups, including women Veterans and racial minorities, are at greatest risk for poor CVD control. This ongoing HSR&D study sought to describe patient-reported barriers to taking their medication as prescribed, and to evaluate patient-level characteristics associated with reporting medication barriers. It was the first to compare whether patients randomized to a clinical pharmacist-administered telephone behavioral/medication management intervention tailored to their needs improve CVD outcomes relative to a control group over 12 months. Of the 428 Veterans enrolled in this study, 352 completed the 12-month follow-up. Preliminary findings show:

Patients in the pharmacist intervention did not show improvement in systolic blood pressure at 12 months relative to usual care.

While the pharmacist intervention did not show statistically significant improvement overall, investigators have yet to conduct within-group comparisons on race, gender, and intervention dose.

Implications: An intervention that addresses multiple CVD risk factors among high-risk Veterans may have the potential to improve morbidity and mortality. Given the national prevalence of CVD, easily disseminated interventions are needed to improve treatment of this epidemic in VA and to help identify how best to serve all Veterans.